The Advancing American Kidney Health Initiative: Do Not Let 80% Distract Us from the Fact that We Can Do Better
Authors: Mallika L. Mendu, Scott D. Bieber, Suzanne G. Watnick, Daniel E. Weiner
Journal: Journal of the American Society of Nephrology (2022)

In their manuscript, "The Advancing American Kidney Health Initiative: The Challenge of Measuring Success,"1 Quinn and colleagues state that the Advancing American Kidney Health (AAKH) Initiative's goals of increasing transplantation and home dialysis to 80% for incident ESKD by 2025 "cannot be plausibly reached by increasing the utilization of home dialysis or transplantation." Although we agree, it is imperative to highlight that the 80% target does not need to be achieved to be successful in the AAKH End Stage Renal Disease Treatment Choices (ETC) model. The Center for Medicare and Medicaid Innovation (CMMI) states that it "did not codify these goals in the final rule," and we expect that CMMI will not formalize this target, while emphasizing that the United States can do far better than the 9.2% of patients with prevalent ESKD receiving home dialysis and 29.7% with a transplant observed in 2019.2 We believe CMMI should acknowledge that 80% is aspirational, otherwise it will serve as a distraction from the objective of providing people with kidney diseases more treatment options while reducing costs. Quinn and colleagues note that, to meet the target, the number of patients considered for kidney replacement therapy (KRT) could be reduced by restricting access, thereby reducing the metric denominator, and they highlight that denominator reduction via restricting access to dialysis will be more important than increasing the numerator of transplantation and home dialysis utilization for success in the ETC. Quinn and colleagues also emphasize the opportunity for greater utilization of conservative management, citing Hong Kong, where >80% of people who receive KRT do so with home dialysis or transplant and where there is a 40% lower rate of KRT than in the United States. Conservative management for kidney failure is underused in the United States. We previously published on opportunities to improve the ETC metric by expanding the number of modality options in the numerator rather than in the denominator, advocating that conservative management should be a numerator item in this calculation. This policy would also require "serious illness conversations" for all individuals with advanced kidney disease approaching the need of KRT.3 The systems approach to expanding conservative management utilization is paramount, specifically to ensure that a patient-centered approach is adopted and incentivized. An approach that restricts care rather than enhancing patient-centered care is not something that kidney care clinicians can support. Accordingly, we encourage the kidney community, including CMMI, to look past an arbitrary 80% number and forgo limiting patient choice to focus on maximizing patient-centered kidney treatment options. Disclosures S.D. Bieber reports having other interests in or relationships as a medical director for a Fresenius facility via receiving compensation for providing dialysis center oversight, and Home Dialysis University faculty for providing a lecture about home dialysis. S.G. Watnick reports receiving honoraria from the American Society of Nephrology (ASN) Board Review Course and Update; serving in an advisory or leadership role for the ASN Quality Committee and the Clinical Journal of the American Society of Nephrology Editorial Board; having ownership interest in Cricket Health; and having other interests in or relationships with Northwest Kidney Centers (a not-for-profit organization) as chief medical officer. D.E. Weiner reports serving in an advisory or leadership role as ASN representative to Kidney Care Partners, member of the ASN Quality and Policy Committees, medical director of Clinical Research for Dialysis Clinic Inc., member of the National Kidney Foundation (NKF) Scientific Advisory Board, and coeditor-in-chief of NKF Primer on Kidney Diseases Eighth Edition, editor-in-chief of Kidney Medicine; receiving research funding from Bayer (site principal investigator; PI), CSL Behring (site PI), and Goldfinch Bio (site PI) (all compensation paid to Tufts Medical Center); and serving as member of the "A Prospective, Multi-Center, Open-Label Assessment of Efficacy and Safety of Quanta SC+ for Home Hemodialysis" Trial Safety and Clinical Events Committee (Avania CRO), member of the "Feasibility of Hemodialysis with GARNET in Chronic Hemodialysis Patients with a Bloodstream Infection" Trial Data Monitoring Committee (Avania CRO), and the chair of the VALOR Trial Adjudications Committee (George Institute Clinical Research Organization [CRO], sponsored by Tricida). The remaining author has nothing to disclose. Funding None.